MANAGEMENT OF ASYMPTOMATIC BRADYCARDIA. Pr. HABIB HAOUALA Service de Cardiologie Hôpital militaire de Tunis

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1 MANAGEMENT OF ASYMPTOMATIC BRADYCARDIA Pr. HABIB HAOUALA Service de Cardiologie Hôpital militaire de Tunis

2 DISCLOSURE STATEMENT OF FINANCIAL INTEREST Grant/research: Medtronic;Sanofi; Novartis Consulting fees/ honoraria: SJMédical; Boston Scientific

3 BRADYCARDIA Asystole Bradycardia < 50 bpm Borderline bpm Normal ( bpm) Tachycardia > 100 bpm Bradycardia < 50 bpm Borderline bpm

4 bradycardia in child

5 Asymptomatic bradycardia A condition in which a person has bradycardia, or a slow heart rhythm, without any of the classic symptoms of bradycardia (dizziness, irregular heart beat, chest pain, shortness of breath, fatigue, and light headedness ) Asymptomatic sinus bradycardia is usually harmless and is often a sign of good physical condition

6 JOUVEN X Cardiovasc Res May;50(2):373-8 Resting heart rate as a predictive risk factor for sudden death

7 Diagnosis of bradycardia

8 Diagnosis of bradycardia

9 Diagnosis of bradycardia

10 Diagnosis of bradycardia

11 Carecterization of the bradycardia Mechanism: Sinus node dysfunction Brady-arrythmia Atrio-ventricular block Frequency Permanent Paroxysmal

12 General evaluation of bradycardia Clinical evaluation Symptoms Drugs Daily activity Sports Familial history of bradycardia

13 General evaluation of bradycardia Clinical evaluation Symptoms Drugs Daily activity Sports Familial history of bradycardia

14 General evaluation of bradycardia Evaluation of the heart Chest X ray Echocardiography MRI CT- Scan Angiography Structural heart disease (Valvular, ischaemic, congenital, Hypertrophic, Dilated ) Normal heart

15 General evaluation of bradycardia Bradycardia evaluation Hours ECG Monitoring TREADMILL TEST ATROPINE/ ISUPREL Test ELECTROPHYSIOLOGY STUDY

16 General evaluation of bradycardia Bradycardia evaluation Hours ECG Monitoring Long pauses Supraventricular arrhythmias Ventricular arrhythmias Chronotropic insufficiency

17 General evaluation of bradycardia Bradycardia evaluation TREADMILL TEST Chronotropic insufficiency Good exercise capacity

18 General evaluation of bradycardia Bradycardia evaluation ATROPINE/ ISUPREL Test Differentiation between intrinsic and extrinsic bradycardia

19 ATROPINE/ISOPROTRENOL TEST Europace Oct;10(10):1176-

20 General evaluation of bradycardia Bradycardia evaluation ELECTROPHYSIOLOGY STUDY Evaluation of sinus node function (Sinus node recovery delay) Evaluation of the AV node conduction ( AH, HV, LWC) Induction of arrhythmias May be useful in suspected ( not documented) bradycardia

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22 SINUS NODE DYSFUNCTION

23 Clinical case 1 22 years old man Handball Player W/H 120 Kgs/ 1,97m He s follwing an hypocaloric diet No symptoms

24 ECG

25 Causes of sinus bradycardia Physiologic extrinsic causes Intrinsic causes

26 The athlete's heart J Physiol Apr 15; 593(Pt 8):

27 Bradycardia in athletes is attributable to High vagal tone J Physiol (2015) pp downregulation of a pacemaker channel in the sinus node J Physiol Apr 15; 593(Pt 8):

28 Extrinsic causes of bradycardia Drugs Digitalis glycosides, beta-blockers, and calcium channel-blocking agents. class I antiarrhythmic agents and Amiodarone lithium, paclitaxel, toluene, dimethyl sulfoxide (DMSO), topical ophthalmic acetylcholine, fentanyl, alfentanil, sufentanil, reserpine, and clonidine Pathologic conditions Hypothyroidism Hypothermia Hypoglycaemia Sleep apnoea Infections Diphtheria Rheumatic fever Viral myocarditis

29 Intrinsic causes of sinus bradycardia Sick Sinus Syndrome. Sinus bradycardia Sinus arrest Sino-atrial block Bradycardia tachycardia syndrome

30 Familial sinus bradycardia Autosmal dominant Point mutation in the HCN4 cardiac ion channel pore Genetic testing could play an important role in the differentiation between benign and mailgnant forms of familial sinus dysfunction Treadmill testing demonstrate normal chronotropic and excercise capacity Milanesi R et al. N Engl J Med 2006;354:

31 Indications of Pacing in patients with sinus node dysfunction

32 BRADYARRYTHMIAS

33 Clinical case 84 Years old man HTA, Type 2 Diabetes Permanent atrial fibrillation Moderate dyspnoea (NYHA class II) No syncope, No dizziness

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35 Sleep apnoea disorder

36 Sleep apnoea disorder Long sinus pauses and AV block can occur during sleep apnea in the absence of symptoms these abnormalaties are reversible and do not require pacing

37 AV BLOCK

38 Atrio-ventricular block Death in patients with untreated atrioventricular (AV) block is due to: Heart failure (HF) secondary to low cardiac output, Sudden cardiac death caused by prolonged asystole or bradycardiatriggered ventricular tachyarrhythmia.

39 So, how should we manage Asymptomatic AV block? First step Is the AVB acute (reversible) or chronic (irreversible)? Workup Clinical evaluation Drugs Biology :Troponins, Serology diphtheria Lyme disease typhoid, thyroid function Imaging (TTE, MRI) Coronary angiography

40 So, how should we manage Asymptomatic AV block? Second step What is the underlying heart disease? Structural heart disease No structural heart disease

41 Indications of pacing in patients with persistent bradycardia due to AV block

42 Indications of pacing in patients with intermittent documented bradycardia due to AV block

43 Asymptomatic chronic high degree/complete AV block permanent or intermittent without structure heart disease Young people Congenital AVB Old people degenerative AVB Pacing indication in CAVB A wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction ventricular rate less than 55 bpm or with congenital heart disease and a ventricular rate less than 70 bpm. beyond the first year of life with an average heart rate less than 50 bpm, abrupt pauses ventricular rate that are 2 or 3 times the basic cycle length, or associated with symptoms due to chronotropic incompetence in asymptomatic children or adolescents with an acceptable rate, a narrow QRS complex, and normal ventricular function. (II b B I B I C II a B II b B Pacemaker is usually indicated ACCF/AHA/HRS 2008 Guidelines

44 Asymptomatic chronic high degre/complete AV block permanent or intermittent with structure heart disease Hypertrophic cardiomyopathy

45 Asymptomatic chronic high degre/complete AV block permanent or intermittent with structure heart disease Hypertrophic cardiomyopathy Congenital heart disease

46 Asymptomatic chronic high degre/complete AV block permanent or intermittent with structure heart disease Hypertrophic cardiomyopathy Congenital heart disease Cardiac surgery/ TAVI

47 Asymptomatic chronic high degre/complete AV block permanent or intermittent with structure heart disease Hypertrophic cardiomyopathy Congenital heart disease Cardiac surgery/ TAVI Implantation of PM is encouraged Muscular dystrophies

48 Conclusion Asymptomatic bradycardia is diagnosed fortuitously It s often physiologically in athletes It can be transient or permanent evolving on a paroxysmal or persistent mode When asymptomatic bradycardia was diagnosed, a workup including heart imaging, ECG monitoring on rest and with exercise should be done to determine : The underlying heart disease The mechanism exact of the bradycardia Indication of the cardiac pacing depend on the two above conditions

49 THANK YOU FOR YOUR ATTENTION